therapy in action · web viewtherapy in action behaviour therapy each chapter of the textbook...

©Routledge/Taylor & Francis 2014

Therapy in Action

Behaviour Therapy

Each chapter of the textbook incorporates a novel case study involving a client presenting with a set

of concerns and a therapist addressing these concerns using the therapy discussed in that particular

chapter. Since each therapy is best suited for certain types of difficulties, each case study is unique

in order to ensure that the examples provided are as clear as possible. This session can be viewed by

watching the associated video content of the therapy session in action and this document is designed

to accompany the observation to support your understanding.

The aim of these case studies is to provide the reader with a real-world example of therapy in

action. Unlike many other fields of psychology, counselling and psychotherapy are not exclusively

academic. In order to fully understand therapeutic approaches and methods, the reader must

appreciate how these concepts can be applied in interactions with clients. The best way to present

these interactions is in the form of case studies and we hope that you are able to use these examples

in order to further your own understanding and practice of counselling and psychotherapy.

The therapy session lasts for one therapy hour (50 minutes) and it is presented as the initial session

in a new therapeutic relationship. Prior to this session, the client will have completed an initial

assessment questionnaire and the therapist will have read this paperwork to ensure familiarity with

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the case (please refer to the assessment form online for more information). Please note that these

videos depict REAL interactions – although the session has been arranged for the purposes of the

video and the sessions will not continue after the recording, the interaction within the session is

genuine. No actors are used in this session. The client was one of the authors and the problem

presented was genuine. The therapist is an experienced practitioner in the field. The only ‘fake’

aspect of this recorded session is that the client did not really seek therapy and this is not really the

first session of a series of therapeutic contacts.

After the conclusion of the therapy session, the therapist is invited to answer a few key questions

about the session. This question and answer session lasts no longer than 10 minutes, thus the video

lasts for an approximate total of one hour.

Therapist Credentials

The therapist in the behaviour therapy session was Keith Mathews. Keith is Senior Psychological

Therapist at the Department of Clinical Psychology, Betsi Cadwalladr University Local Health

Board. Keith works in secondary care community adult mental health services, working with

individuals with complex and enduring psychological difficulties. He is trained in cognitive

behavioural psychotherapy, dialectical behavioural therapy, schema therapy and integrative

psychotherapy. He also supervises practising psychotherapists and trainee clinical psychologists. He

has taught cognitive behavioural therapy process skills on the North Wales Doctoral Programme for

Clinical Psychology and currently teaches schema therapy on the same programme. Additionally,

Keith teaches assessment and formulation skills on the Masters in Therapeutic

Counselling programme at Coleg Llandrillo Cymru. Keith is a Senior Accredited Practitioner with

the British Association for Counselling and Psychotherapy

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Client Presentation

The client in the behaviour therapy session was Fay Short. Fay has an acute fear of heights. She has

recently experienced high levels of stress at her workplace and some associated physical symptoms

(including headaches and backache). However, her primary reason for seeking therapy is a desire to

overcome an intense fear of heights. She has previously experienced person-centred therapy for a

short space of time over ten years ago, but this was unrelated to her current fears. She would like to

overcome these fears during therapy so that they no longer impact on her ability to take part in

activities that involve heights.

Transcript of Session

T denotes therapist, C denotes client.

T: Hi Fay, nice to meet you. As you know, my name’s Keith and I’m a cognitive therapist so just

before we get chatting about the difficulties that have brought you here, I just want to let you know

that today’s meeting is, of course, confidential. The limits to confidentiality are that I will be

keeping some notes just to make sure I’m up to date with what’s going on in the sessions so I can

refer to, as a record of them, but also that if there was any concerns around risk I’d need to have you

to be able to go to appropriate sources whether it’s a GP to talk about concerns, or if there’s risk to

yourself or other people. Is that acceptable?

C: Yes, that makes sense.

T: Okay. My notes are open so if there’s anything you’d like to read in them, and at the end of the

sessions I will destroy them.

C: Okay.

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T: Okay. Now you gave me a bit of information when we talked on the phone the other day about

some of your difficulties, I understand it some concerns you have around being in situations where

there’s sort of height involved.

C: Yes.

T: So what we’re going to do today, I’m going to ask a bit about the problems that you’ve been

facing, how it’s affecting you, the type of difficulties you’ve experienced in relationship to this and

how it’s affecting your life, and then try to get an idea about what’s holding the problem together so

we can start to focus on ways to try and help to overcome this problem.

C: Okay.

T: Okay, before we start is there anything you would like to ask me, is there anything you would

like to know about myself or about the therapy itself?

C: No, I think that’s clear, I think that the confidentiality thing would have been a question but

you’ve kind of covered that.

T: Okay, well if at any point during the sessions that you want to ask me about myself I’m more

than happy to share that with you. Okay. So perhaps we could start by just telling me a little bit

about your problem and how you are affected by that at the moment.

C: Okay, so as I said on the phone it’s a fear a fear of heights, and it’s, on a day-to-day basis it’s not

hugely problematic, I don’t live in a tower block or anything, but basic things like, erm, being able

to go to the top of a ladder to clean windows at the top of my house, or touch up paintwork at the

top of my house is problematic.

T: Yes. Uh, huh.

C: Travelling in lifts, if I think about it. I actually had a nightmare just remembering the other day

about being in a lift and it breaking and it plummeting, erm, so those kind of things. Generally I’m

not outside in the open air where there’s a risk of falling all that much, but for those types of

situations I suppose for me the bigger issue is when I travel so my husband and I like to travel a

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little bit and see the world a little bit, and inevitably that means either flying which involves going

up very, very high or when we visit places we always seem to end up in a situation where you need

to go to the top of something like the Eiffel Tower or a pyramid or whatever.

T: Yeah, so it sounds like it’s affecting sort of more day-to-day things like you know, sort of

cleaning your windows, things like that, but also particularly around when you go away you find

yourself in situations where, I guess, you’d rather not be in.

C: Yes.

T: Okay, okay, and it sounds like it’s affecting you in terms of the content of your dreams as well.

C: Yeah, yeah.

T: Okay. So, just to give me a little bit of an idea about when this started to become a problem for

you and your understanding about how it’s developed as a difficulty for you.

C: Okay, well, I’ve always been nervous of heights, so for as long as I can remember I’ve always

been a bit anxious about going up high and, you know, going up ladders or when you have rope

bridges and things like that, those types of things, but it’s never been a very, very strong fear. And

then about three years ago my husband and I went to Cambodia. We were volunteering over there,

but we visited the temples in Angkor Wat, an absolutely amazing place, and most of the temples

you can climb to the top and you get a view of all the surrounding countryside which is amazing.

And the way that you climb them, a lot of them are these stone steps and they were fine, I managed

with those without a problem, but there’s one particular temple and it’s completely, completely

vertical. It’s not completely vertical but it’s practically vertical, and the way you got up it, they’d

kind of bolted this wooden ladder to the side of it, and you essentially just climb this ladder. And it

was very, very, very high and the ladder wasn’t in the best condition. And so, initially my husband

was going up there and I said I’m not going and I sat out, and while I was sitting there I watched

him go up and I saw a man coming down with a baby, was carrying a baby down the ladder and I

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just, I felt so embarrassed that I couldn’t do it, and there was a guy carrying a baby, so I decided

that I was going to do it anyway.

T: Right, yeah.

C: And I climbed up the ladder and I about half way up it really hit me and I started to feel really

dizzy and I started shaking and I couldn’t breathe properly. So really I’m just absolutely terrified,

and by the time I got to the top I was crying and I think I climbed, I crawled over the top of the

ladder and just sat down on the floor and no one could move me at that point.

T: So it sounds like it’s a really distressing experience and it sounds like it was something that was

influenced by you seeing that guy climb down. It sounds like your initial sort of urge was not to go

up.

C: Yes.

T: But there was something about seeing that guy coming down, I’m just wondering, I mean it

sounds sometime ago this but do you have, do you have any recollection about what was going

through your mind when you saw this guy coming down with a baby?

C: Well I was, I was cross anyway that my husband did it and I couldn’t because I kind of feel, it’s

a little bit like anything he can do I can do as well, I mean within reason, you know, if it comes to

bravery that kind of thing, I like to think I would do, I mean not to a ridiculous extent, he could lift

something that I couldn’t lift because he’s a lot stronger than I am and that’s fine, but in terms of

when we went to the Eiffel Tower even though I don’t like heights, we went to the same level and

we always do do those things together, so I was already feeling a little bit disappointed in myself.

T: So, so at the beginning when you saw your husband going up and you’re thinking to yourself I

really prefer not to do this, there was, what were you telling yourself as he was climbing up there?

C: I was telling myself that I really don’t want to do this but I’m actually really disappointed in

myself for doing this, it’s pathetic, it’s stupid. Why can’t I go up? And then this guy is coming

down with a baby and then it’s even more stupid, there’s somebody coming down carrying, not

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even holding on properly can bring a child and, I mean, okay one of my thoughts was that guy’s

really stupid for taking a child up there, but in the main I was thinking it must be safe and I’m just

being a complete coward for refusing to go up there.

T: So on one hand you were sort of saying that guy, it’s not the best idea to do that, but on the other

hand you were sort of making quite a lot of sort of judgements and evaluations about yourself?

C: Yeah, I suppose I was, yes.

T: Okay, so I’m asking you that just to sort of get a sense of what was going on for you as you

anticipated going up this ladder in the temple. And it sounds like as you climbed the ladder there’s

lots going on for you inside yourself, physically you were noticing lots of sensations and just sort of

again I know it’s a long time ago so were there particular things that you would notice about what

was going on in your body that you were paying attention to?

C: Yes, most definitely because that was the really scary thing for me. It wasn’t, it wasn’t so much

heights, it was the fact that I couldn’t control it, so I was physically shaking and just felt really

really weak and kind of, you know, I’ve only ever fainted once in my life, but you know that feeling

where the world starts to kind of recede a little bit and you feel like you might just pass out, and

then just not being able to stop crying and that was a really scary place

T: So really really distressed, but also just for me to make sure that I’m picking up the right things

which seem to be influential in that experience, erm, you were noticing sensations and sort of

sensations you associate with fainting ...

C: Yes.

T: ... and I’m just wondering when you noticed those sensations was there any sort of thoughts

about what might happen or what would happen to you?

C: Well, I mean, given that there was no safety net or harness or anything like that, the only thing

that I could think kind of over and over again, I suppose I had two thoughts and one of them was

'This is utterly ridiculous that you are getting this wound up about something that really is quite

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simple, you’re just walking up a ladder, it’s not scary at all' and on the other hand I was thinking

'Oh my gosh, if I do actually black out I’m going to fall backwards and I’m going to probably, at

least seriously hurt myself if not kill myself'.

T: And at that point when you sort of had these two this is okay, one 'This is okay, it’s just climbing

a ladder' and the other though was 'Gee I could black out and fall backwards' imagining you think

you could hurt yourself badly ...

C: 'I’m probably going to die' is probably the thought that was going through my mind.

T: So it was really quite an intense thought.

C: Yes.

T: And can I just ask you, what we do in cognitive therapy will often ask people to rate the strength

of ideas so, you know, as that thought was running through your mind, say 10 was that it was really

believable that you really thought that was going to happen, and 0 being you didn’t really believe

that, how would you rate that from 0 to 10?

C: I would say 10, I firmly believed that I was gonna ... okay, maybe a 9 I think. I suppose if it was

a 10 I’d have probably just clung to it and refused to move, and the fact was I did keep moving ...

T: Right.

C: ... apparently the tour guide afterwards mentioned that apparently there has been a case where

they had to get out air rescue to remove someone from the top of this temple because they couldn’t

get back down again, they panicked.

T: They just froze.

C: And that didn’t happen, thank goodness, so ...

T: So, it didn’t, but to all intent and purposes you really believed that something really bad was

about to happen?

C: Yes.

T: Okay, so, and you got to the top.

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C: Yes.

T: And what happened then when you got to the top? You kind of, in a sense, disproved you were

going to fall, but was that any consolation?

C: No. No I was convinced I was going to fall going back down. I think going up something is, in a

weird way, better than going down because you’re not, you’re not looking where you’re going and

so I ended up going down backwards because then I wasn’t having to look at the drop. So when

you’re going up something you’re looking upwards and therefore you’re not thinking about the drop

behind you. Whereas coming down usually you’re more forwards, and some people were coming

down forwards, so when I say ladder it’s a complete ladder, it sticks out and it is possible to go

down forwards but it’s practically ladderish, and I didn’t, I went down backwards and clung on to it.

T: So, okay, so when you clung on to it that’s what you were doing holding on really tight. So how

did that go as you were coming down the ladder?

C: Very, very slowly.

T: Right.

C: The other people coming down, because there’s only one ladder, the other people were actually

climbing off the ladder and climbing on the rocks to get round me because it took such a long time

for me to get back to the ground.

T: So it sounds like you’ve got this really vivid image of what was happening, and the image that

you have is of you holding on really tight, taking your time I would imagine.

C: Yes.

T: And people almost climbing around you ...

C: And me swearing at them, in my head, not out loud (laughs) ... that could’ve been awkward.

T: Okay. So what was, what was running through your mind as you saw these people climbing

around you?

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C: I think I was just really, really embarrassed. Embarrassed that I was panicking this much and

really scared that I couldn’t control it, so I was just thinking that, that it’s stupid, that I should be

able to control this and that I’m not going to fall, I’m holding on, I’m perfectly capable of walking

and that’s all I’m really doing so it’s stupid for me to feel this anxious, and yet at the same time also

thinking 'Oh my gosh, if I let go for a second, that’s it, I’m going to fall'.

T: So the holding on wasn’t based on that thought 'If I let go, if I don’t hold on really tight

something really bad is going to happen to me'. It sounds like there was another train of thought

which was saying 'I’m really making a bit of a show of myself here and people are sort of really

noticing me' so feeling kind of embarrassed, yeah, okay, and uncomfortable about the situation you

found yourself in, and the other thought was along the lines of 'this is something I can do', am I right

thinking that?

C: Yeah, but in thinking 'this is something I can do' it wasn’t a positive thing, it was a 'you’re being

an idiot for not being able to do this'.

T: Right.

C: So it was a very kind of ...

T: Okay, so that’s clarified that, it was a really quite a judgemental thought.

C: Yeah.

T: Okay. So, and what happened after this ... you clearly got down ...

C: (laughs) I’m not still up there.

T: You’re not still up there ...

C: I’m very glad ...

T: So that’s good to know, and what happened after that? What sense did you make of what

happened to you?

C: Erm, the thing that really struck me was that I couldn’t control physically how I reacted.

T: Okay.

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C: And that was, that really, really frightened me because I’ve always kind of prided myself on, I’ve

always thought that in a bad situation I’d be able to talk myself round, so I’ve always thought, you

know, I might be frightened but I would be able to logic my way out of it and I’d be able to talk

myself round but the reality was I couldn’t, I was just so frightened that physically I just had a

really bad reaction.

T: Now I know this is some time ago and retrospective estimates are quite difficult to keep, one of

the things we will be doing is asking you to keep a record of these types of thoughts like you notice

in these situations. But in terms of that sort of, the thoughts that you have, and it sounds like you

have quite a lot of different thoughts you are having, which was the thought that really upset you the

most as you were, sort of, thinking about what had happened?

C: I think the fact that I couldn’t control it was probably the thing, I think if I was gonna, after the

fact obviously there isn’t the thought 'I’m going to die' because I’m no longer in that situation so

that becomes negligible but the thought that firstly 'I can’t control this', erm, secondly 'if this

happens again, again I’m not going to be able to control this' and thirdly 'oh my gosh, how

embarrassing, everybody thought I was stupid'.

T: Okay, so it sounds like there’s a few thoughts, there’s thoughts in the situation itself which is

'something really bad’s going to happen to me, I could kill myself'. Alongside that there was this

real sort of self-consciousness about how other people might see you; the thought that seemed, in

that situation at least, to be really sort of difficult for you was about being in control ...

C: Yes.

T: ... being able to control yourself. Because it sounds like, you know, you’ve always been able to,

sort of, deal with these feelings okay.

C: Yeah.

T: Okay. So, after that event, how were things for you after that event in Cambodia?

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C: Well, they were actually worse, so prior to that we’d been up several temples, and I’d been okay,

none of them were as high as that, and I’d managed. After that it just, even a slight height and I

would feel really, really anxious and just quite panicky. Even if it was like a ridiculously small

height it just, even climbing a very small ladder and then having to hop across something I just

would feel really, really anxious about it.

T: Okay, and again so when you were noticing feeling anxious what was, what sort of thoughts

were going through your mind, what were you making of that?

C: I think I was mainly embarrassed, embarrassed that I was getting this wound up again and this, I

could kind of excuse the previous one because it was very high and it was dangerous, but then it

was small heights and I was getting, I was starting to shake and feeling my breathing going and so I

was just really embarrassed and telling myself it was stupid.

T: Okay. So it sounds like again there’s lots of sort of evaluations about yourself in relationship to

those situations that you’ve been finding kind of scary, but then there’s quite, sort of, negative

judgements about yourself I guess?

C: Yes, yeah.

T: And was there anything that you’d sort of come across that you’d sort of thought could help with

these thoughts and feelings that you were having when you were in those situations, did you come

across any solutions or anything that you thought would help around that?

C: No, I suppose avoiding going up there, going on anything high. Usually if my husband’s with me

then that makes things a little bit easier.

T: So having your husband in close proximity to you.

C: Yeah, so that makes things easier, and not having other people there helps, so if I’m on my own

then I can kind of do it in my own time, and so the less people the better really, because I’m not

really thinking about other people watching me

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T: So let me just sort of sum this up then, Fay. So, following that experience in Angkor Wat there’s

been a set of sort of thoughts that you had at that experience, but it sounds like after that it

continued, you’re really sort of watchful about those feelings, how you might feel in situations and

quite aware of how you might appear. And since then it sounds like you’ve found, erm, ways to try

and minimise those concerns and those worries that you have, and one of those is by keeping your

husband, your husband’s name is?

C: Colin.

T: Colin, okay. So by having Colin close, and by staying away from other people in those situations,

that is something that you found brings your anxiety and discomfort down?

C: Yes, I think so.

T: Okay. I’m just sort of thinking, from those events back in Cambodia, can you just give me a

sense about now how it affects you and have any of those sort of thoughts have they occurred since

that time?

C: Erm, well, on a kind of ... so there’s been a couple of times, so last Christmas we went to

Australia and there were three notable occasions. One of them, we went into the water, in quite deep

sea water, and I’m not a swimmer and I’ve never really liked the water. I sound like I’m riddled

with phobias, I’m not terrified of water and I can swim, I’m just not a strong swimmer and so it

would be silly to go into dangerous water, but on this occasion I realised in the water, we were

swimming with dolphins and we got into the water, and it was just seeing the drop underneath me

and the same sort of thoughts were coming then, and my real fear was that I was just going to go

into panic and was just going to start splashing about and panicking and not being able to swim, and

that would be very embarrassing.

T: Yes, and I was going to ask you then, what was the meaning that had for you at the time. Can

you picture yourself there in the water; can you imagine yourself being there? What was running

through your mind at the time, about what people would notice, what would happen?

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C: I think what I was thinking was that if I panic one of two things would happen, I’d either drown,

which is awful because obviously drowning and dying isn’t great ...

T: Not good for your health.

C: Definitely not ... or, or I will start ridiculously thrashing about and making a complete scene and

somebody is going to have to rescue me and drag me out of the water.

T: Okay.

C: And everybody is just going to think that I’m an idiot.

T: So there’s two things that you really feared at that point, one is that you could die, okay and as

you say that’s real grounds for feeling really scared when you believe that’s going to happen, and

the other thing was actually you’re going to really stand out and you’re going to make a bit of an

idiot out of yourself and everyone will notice and pay attention to you. Okay, and what actually did

happen?

C: Er, in that particular situation the pod of dolphins came by and the second you see a dolphin

within arms reach you just, everything else just went completely out of my head and I calmed right

down, er, so I think it was a very, I think if I’d just been in water it might have been a very different

situation but it was a complete distraction, there was no way I was going to be thinking about

anything other than the fact there was this amazing creature next to me.

T: So it really sounds like when you became distracted and you started to focus your attention away

from these thoughts, actually your feelings changed quite dramatically and your anxiety levels came

down.

C: Yeah.

T: Your physical discomfort came down as well?

C: Yes.

T: Yeah, and it sounds like you started to attend and focus your attention on actually what sounds

like a fantastic experience. Erm, have you noticed anything similar, you know, in other situations

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because the themes that we seem to be talking about here is (a) is that something really bad can

happen to you in these situations which seems to have a real effect upon, physically how you feel

and emotionally how you feel and it sounds like it influences your behaviour, so for instance it

sounds like you hold on really tight or you get close to your husband, yeah? And the other one that

seems to happen is that you actually really start to be aware of other people and how you’re going to

appear towards other people, and it sounds like then, you know, you feel really uncomfortable,

really anxious. Physically I imagine you feel pretty uncomfortable too?

C: Yes.

T: What I wasn’t sure about, what is it that you do at times when you’re just aware of people and

that they might notice you. What do you do to try and manage that?

C: You mean if I’m not high, if it’s not a feeling of heights situation, so just in everyday life?

T: Well it could be either, I’m just sort of thinking in relationship to these situations, the problem

seems to be in high situations or like in the sea when you’re aware of the translucent sea and you

can see the sea floor and it’s, you become very aware of other people around you. And is there

anything that you do in that type of situation to try and manage it, or to stop it from happening,

these things such as people might start to notice you getting upset or distressed?

C: Other than avoid the situation, or try to, try to not look like I’m distressed and I think that’s what

really scared me in Cambodia because I couldn’t stop myself. So normally I would put on a brave

face and pretend I’m fine, and for the people around me, I mean usually my husband knows because

he knows me and so he will be, he will know if I’m really anxious, but to anybody else I wouldn’t

appear it, but that’s part of my job, I’m a lecturer and I don’t think there’s a lecturer alive who can

honestly say that they don't feel a little bit nervous before they get in front of 300 students and give

a lecture.

T: Yes, it’s normal to feel uncomfortable when you’re in a social situation when you are the focus

of attention ...

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C: But normally in those situations I’ve put myself there and you just take a deep breath and get on

with it, it’s fine.

T: Sure. So it sounds like it’s quite different from your day job when you actually are on show, to

situations like this, and I wonder what you’d, how you’d account for the difference between those

two different scenarios because they sound ... they have similarities but there’s quite a different

viewpoint you hold about them.

C: I guess there’s two things, one of them is I have control in one situation and I don’t have control

in the other. I have control over what I do if I’m lecturing, or in any of those situations whereas if

I’m, if I’m trying to climb something and if I’m shaking I don’t have control over that and if I’m

crying I don’t have control over that. And the other thing is competency, when I’m lecturing I know

I’m competent at what I’m doing, I’m not doing something that I think I’m at risk of failing. If I’m

trying to swim I’m at risk of looking stupid or drowning or if I’m trying to climb something I’m at

risk of panicking or crying or doing it badly.

T: Okay, so can I just reflect that back to you. So when you’re in a situation such as lecturing you

feel competent and in control and you feel confident and you are able to portray that so of 'I’m in

control, I’m capable'. It’s that situations when you feel you’re not in control and you don’t feel

competent and you’re judging yourself in some way in a negative way in terms of your

performance, that’s when you start to feel really uncomfortable and what this also seems to be

associated is that’s prompted by a fearful situation like being in a high place.

C: Yes.

T: Is that a fair summary?

C: Yeah, I think so.

T: Okay. Now, I’m just sort of thinking now in terms of helping to help you understand the process

of cognitive therapy, now I’ve been asking you lots of questions about your thoughts, and you

might be thinking why he isn’t asking me when actually the fear I have is heights, but it seems that

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actually the judgements that you make seems to be a key factor in this, about yourself in terms of

yourself in relationship to others, but also about what might happen to you as well. Now in

cognitive therapy what we’ll be looking at is these relationships between situations such as being in

these high places, and the sort of evaluations about yourself about what might happen in the future

and how other people might perceive you. They’re called triads. And what we look at in cognitive

therapy is to help you to sort of recognise how those sort of thoughts you might have about yourself

in these types of situations, how they influence your responses in terms of your emotional

responses, your behavioural responses, and what you might do to prevent some of those predictions

that you make.

C: Okay.

T: Okay, with a view that actually thoughts I guess are a hypothesis based on the best available

evidence that we have available at the time. Yes?

C: Right.

T: And I guess what you might be able to say after the event is 'actually, well I can see that quite

differently at the time'. So we need to become aware of our thinking. What we do in cognitive

therapy is to help people start to notice their thoughts and how their thoughts, they tend to sort of be

judgemental, or they might tend to may be what’s called overgeneralised, they can start to become

problematic for the person. Okay. So what we’re helping to do is help people to start to notice their

thinking patterns, so then people start to become more aware of them, with a view to help them to

start to create a, if you like, evidence for and against them so that people can come out with more

balanced thoughts.

C: Right.

T: Okay. Does that make sense?

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C: It does, so it’s about, it’s about having a more logical thought processes and balancing the

evidence that’s available so that you can make a judgement based on evidence rather than based on

bias or something.

T: And what we’re looking for is balanced thoughts, rather than negative or positive thoughts,

because sometimes positive thoughts are irrational thoughts, you know, I guess if we were to have a

party in the middle of the A55 and had a positive thought about a juggernaut coming towards us that

might not be a very helpful thought ...

C: No.

T: So what we’re looking for is a balanced thought which takes into account both sets of evidence,

you know, both in the sense of, you know, when I’m on a ladder it’s scary and it’s fearful but that is

set against the others, that actually when I’m on a ladder generally I tend to do well and I’ve got

experience and I know that I can usually manage these situations. So taking those into account

you’d arrive at a more balanced thought. Does that make sense?

C: Yeah.

T: Yeah, okay. But sometimes what also people do is what you’ve mentioned, is staying away from

situations because you anticipate that actually that is going to be something scary and difficult. So

also what we need to do is help you to sort of think about situations that you’re staying away from

because that also prevents you from finding out whether you’re able to manage those situations or

not, and also because avoidance tends to be a way of maintaining difficulties in the long term.

Okay. Now what I wanted to ask you about is actually had you considered what the goals were for

this treatment for yourself?

C: Well, I can, a long-term goal, this summer I’m hoping to go to Snowdonia, I have a friend

coming over from Australia to stay with us, and we’d like to go walking, and I feel very anxious

about the idea of going up mountains. Obviously walking, and hills and things seem fine, but the

idea that it might be kind of rocky, unstable terrain and then there might be a sheer drop and I might

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have to walk along the edge of that drop. So I guess a goal for me in the long term being able to do

that without, because loads of people do that so I guess looking, thinking about balance, that’s

sensible to be able to do that. I’m not suggesting going rock climbing because I don’t think that’s

something that I would want to do but, to just to be able to do that without feeling terrified.

T: So something that you aspire to do this year with your friend coming over from Australia is to be

able to go for a walk, and be able to sort of do that with a degree of calmness.

C: Yeah.

T: Yeah, okay. When you think about that now, what thoughts does that bring to mind, what sort of

ideas does it generate?

C: Erm, I can imagine getting half way up, with the aim being to get to the very top and having to

cross an area that has a sheer drop and just not being able to do it.

T: Right.

C: And the thought of my friend being there and me not being able to breathe and shaking and just

having to turn back, I just think that he would think that I’m just really stupid, and that’s just a

really ridiculous thing to happen.

T: Right, so again there’s quite a lot of predictions which sound quite similar to the ones you’ve told

me about just now, that actually there’s two parts, there’s (a) that you would lose control and (b)

that actually people with you would then judge you, and the consequences of that I guess. Okay, is

that a fair summary?

C: Yes, I think so, yeah.

T: Yeah, okay. So in terms of the actual problem, how frequently are you getting these difficulties,

what sort of problems are they bringing to your day-to-day life?

C: In general they’re not a huge day-to-day thing as I’m not often up high, but for really practical

things, just really simple things like being able to go up a ladder at home to be able to change a light

bulb, or clean the upstairs windows, those kinds of things I just, I won’t do those things.

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T: So in terms of the longer term goal like maybe going for a walk in the mountains when friends

are around and so forth, but I’m just wondering, is being able to do some of these sort of things that

you’re currently staying from, is that something else as well?

C: I think so, yeah, being able to do it comfortably so, I think that I would if, if I didn’t have

somebody else to do it I probably would do it. I wouldn’t allow my windows to get dirty, but I think

being able to do it without the, the big build-up and the fear that comes with it would be a good

goal.

T: Okay. So now I’m just thinking in terms of the sort of problems that were identified to you in

this chat we’ve had so far, then there’s definitely clear fears of certain situations. Alongside those

sort of situational fears, which I guess are called phobias, there’s also the thinking we’ve identified

in relationship to judgements about yourself coming to some sort of sticky end, in which you are

going to come to some harm, serious harm. There’s the thoughts about how you might be perceived

by others and what you try to do to prevent that from happening, and it feels like you’ve also

developed a set of behaviours to try and prevent those things from happening, okay. That seems to

me, from what you’ve told me, as being the presenting difficulties. Is there any problems that I

haven’t touched on which you feel are, which would help me understand what the overall problems

are?

C: No I think, I think that seems to be all of it, the not being in control is a big thing and the other

people thinking that I’m, that that’s ridiculous and thinking that I’m stupid for not being in control

is a big thing. And, yeah I think that you’ve kind of covered that.

T: So if we were to sort of prioritise them as you like our problem list and we focus on those, we

will need to prioritise which you’d like to look at first so we can work on ones which are key for

you to overcome.

C: Okay.

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T: Now what I’m also mindful of is about you know people come to therapy but often they don’t

often know the ins and outs of what the therapy is about so would it be helpful if I was to just sort of

go over what you’d expect from therapy?

C: Yes. That would be good.

T: Okay, cognitive therapy tends to be a short-term therapy, that’s why we sort of need to think

about what your goals are, and also to actually identify clear problems, so that we can link the goals

to the problem, so that we’re helping you to work towards something that you want to change. Now,

cognitive therapy is very much an interactive therapy, it’s not something I do to you, it’s, it’s a

collaborative based approach, and the idea of cognitive therapy, it’s a bit like the analogy that’s

often used is, you know, with a runner they might have a coach, but the coach doesn’t do the

running. The coach helps them to identify problems in sort of their behaviour because the goal is to

run an effective race. But sometimes actually running that race is hindered by certain things that we

might do. So my role as a therapist is really to act as a coach to help to identify areas in relationship

to these problems that we can fine tune and make changes in so that you can actually run this race

more effectively. Okay, does that make sense?

C: Yeah, that makes a lot of sense.

T: And part of that, is actually it’s really important that you can give feedback to me and that we

can generate ideas to help you to overcome this so I can come up with ideas, but you can come up

with ideas, with a view to helping you to check out your thinking.

C: Right.

T: Yeah, in terms of some of the ideas you have, some of the thoughts that you might have about

these particular situations that you fear, that you’ve learnt to fear. But also to help you test those

thoughts out, so we’ll be doing things like asking you to keep thought records and diaries, noticing

the type of thinking that happens when you’re introduced to these situations, and noticing how you

respond as a consequence of those thoughts. Does that make sense?

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C: Yes. When you say 'to test the thoughts out' what do you mean by that?

T: Well for instance what can sometimes be very helpful is that when people you know might have

sort of a judgement about sort of this might happen for instance you know 'I’m going to make a fool

out of myself', 'I might get really noticed' then actually what we encourage people to do is to think

of that like a hypothesis you know so it’s like 'I worry that if I do this I’m going to get noticed'

rather than 'if I do this I will be noticed', so to tell the difference between like a worry and actually

an event.

C: Right.

T: So it’s to help to test the thoughts out, to gather evidence for the thought, if it’s accurate or not.

And if it’s not accurate, what might be a more accurate thought so we can update our thinking of it

really, yeah. Does that make sense?

C: Yeah, yes it does.

T: Okay, is there anything that we’ve talked about so far that you’re not sure about?

C: No, no I think, I think I’ve followed pretty much everything that you’ve said.

T: So part of what we’ll do is about introducing you to situations that you fear, helping you to keep

a record of your thinking, helping to help you to develop skills in testing out your thoughts and

replacing those thoughts with more sort of balanced thoughts if you like, with a view that ultimately

that the role is that you become your own coach ...

C: Right.

T: ... so that I become redundant. The whole idea is that you sack me in the end.

C: Right.

T: But with the skills to be able to do this yourself. So that’s why cognitive therapy is short term,

fairly short term, and what we’re talking about short term is about up to ten sessions.

C: Right.

T: Okay, is that within what you’d expected?

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C: Yes, I think so, yeah.

T: Okay. Now the sessions are usually once a week and usually last for 50 minutes, and we meet

here and we use the sessions to refocus our attention to understand the problem, to develop an

understanding of the problem which is called formulation and then we use that like a psychological

map of the problem, so we use that to inform how we go about the treatment. So the first few

sessions will be gathering information, so keeping diaries, keeping sort of observational records of

your thoughts and how you responded to your thoughts, and then once we’ve got a really good idea

about what’s going on, to help you to try and test out some of those thoughts. So you can update

your beliefs about what might happen to you either in relationship to what might happen in the

future, how people might view you, and also to help you to be a bit more sort of kind towards

yourself in terms of the judgements that you make as well because it sounds like you can be quite

harsh on yourself at times. Does that make sense?

C: Yes, yeah, so it would be keeping diaries of the things I think about and then bringing them to

this session so that we can talk about that and identify problems and those thoughts and then maybe

testing out thoughts to see if they are actually true or not.

T: That’s spot on, yeah that’s great. Now what I’ve got with me, is because I knew that you had

some difficulties with situations which are often termed phobias, I’ve brought some information for

you to take away to read to give you an idea about how phobias develop and how they are

maintained, but also some information about cognitive therapy so you can sort of gen up on it so

you can become more aware of it and ultimately to become skilled at applying this to yourself. How

does that sound?

C: That sounds good, yeah, it’ll be good to learn a little bit more about it.

T: Yeah, okay. We’ve got about two or three minutes left, is there anything you’d like to tell me

about the problem that we haven’t covered so far? Is there anything that we haven’t touched on?

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C: Erm, no I think, I think it’s been really helpful to kind of think about those thoughts that I’ve had

and it’s, I’ve never really thought about it in those terms before, so it’s been really interesting to

think about it in terms of the lack of control and other people's reactions to that, and what I think

about the lack of control and other people's reactions to that, so I think that’s been really interesting

but we’ve covered pretty much everything now.

T: Okay. Well how about if we actually set a time maybe next week when we can get together to

talk about it in a bit more detail?

C: That sounds good.

T: Okay.

Analysis of Session

The therapy session can be sectioned as follows.

Introduction

Introduction outlining basic contractual details, especially the limits of confidentiality

Focus specifically on the problem presented by the client and an outline of the intended

coverage in the session (map of the session)

Invitation to ask questions

Story

Client is invited to explain how the problem began, how the problem has developed over

time, and how the problem impacts on current life

Focus on thoughts experienced during experiences of the problem, including rating the

strength of the cognition

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Goals

Cognitive therapy is explained in terms of how thoughts can influence our feelings and

behaviours

Explained how thoughts can be tested for validity to reduce problem cognitions

Identified a specific goal for therapy in the near future

Ending

Outlined the expected duration and content of future sessions (map of the sessions)

Explained that homework will be set each session, such as experiments to test validity of

thought processes and diaries to record thoughts

Set readings as an initial homework

Reflection on how the session was experienced by the client

Invitation to return for future sessions

Key questions to consider in relation to this therapy session

How could the nature of this client be understood from the cognitive perspective?

What does the client appear to think about herself?

What does the client appear to think about the world?

What does the client appear to think about the future?

Does the client hold a positive or negative view of herself, the world and the future?

Does the client hold thoughts based on available evidence?

Is there any indication of any cognitive distortions?

How do the thoughts held by the client impact on her feelings and behaviours?

What is the nature of the therapeutic relationship in this cognitive therapy session?

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Is the therapist honest and open?

Does the therapist have a good rapport with the client?

Does the therapist challenge any cognition held by the client?

Are there any positive or negative effects of challenges to the cognition held by the

client?

Does the therapist suggest any experiments to test cognitions?

Which cognitive techniques are demonstrated in this therapy session?

Which Socratic questions does the therapist use?

How does the client respond to Socratic questions?

How does the therapist encourage the client to identify cognitive distortions?

How does the therapist encourage the client to defend the cognitive distortions?

Does the therapist test any cognition for validity and what is the outcome of this test?

Personal experience of the client

I felt a little bit anxious about this session because it was my first experience of cognitive therapy as

a client (and I was a little worried about being filmed disclosing potentially personal information!).

However, my fears began to reduce as soon as I started talking to Keith. We established a good

rapport and I felt comfortable sharing my experiences with him. He seemed to be genuinely

interested in my story, and this was contrary to my expectations (I had previously experienced

person-centred therapy and I thought that cognitive therapy might be less relationship focused and

more business-like).

I shared my story with Keith at the start of the session and I quickly forgot about the camera. I

found his questions both engaging and frustrating at times – I often wanted to talk about how

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something ‘felt’ but he kept drawing me back to my thought processes. Although this was initially

rather challenging, I did begin to see the value of this focus as he started to explain the way that my

thoughts can impact on my feelings. His explanations in the later part of the session were

particularly helpful and I think that I gained a good understanding of how my thoughts are helping

to maintain my problem.

During this session, I realised several things for the first time. In particular, I realised that one of my

primary concerns about heights relates directly to my own self-confidence. I have a firm belief

about myself – I will look stupid if I panic – and this thought leads me to evaluate myself in a

negative way. This means that I feel a strong need to constantly maintain control over myself and

the wider world, and I recognised that this is both irrational and impossible. This increased

understanding of my own fears has helped me to understand my anxiety a little better, and I now

realise that it is only by facing this fear that I might be able to ‘prove’ to myself that it is not always

‘stupid’ to lose control. Alongside my low self-confidence and need for control, I also realised that I

hold a more legitimate fear of falling. This seemed very sensible to me at the start of the session

(and I guess that I believed that this was why my phobia was justified). However, during the

session, it became clear to me that my fear is far more exaggerated than is reasonable in the

circumstances.

At the end of the session, I had a clear understanding about cognitive therapy and a road plan for the

future sessions. I was confident about my ability to tackle my concerns and I actually felt quite

eager to get started on some of the readings suggested in the session.

Fay Short

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